In this episode of Hospital Medicine Unplugged, we sprint through inpatient gout—confirm the diagnosis, kill the flare fast (safely), and treat to target so patients stop bouncing back.

We open with the do-firsts: aspirate the joint or tophus when feasible to see MSU crystals under polarized light—doubles as a septic arthritis rule-out. If aspiration’s a no-go, lean on classic features and, when needed, ultrasound/DECT—but don’t anchor on serum urate alone (can be normal in flares). Map comorbidities/meds (CKD, HF, diabetes; diuretics, low-dose ASA, CNIs; CYP3A4/P-gp interactions).

Acute flare playbook—individualize, start early:
• Colchicine (low dose): 1.0–1.2 mg, then 0.5–0.6 mg 1 hr later; then 0.5–0.6 mg once/twice daily for 7–10 days. Avoid with strong CYP3A4/P-gp inhibitors or severe renal/hepatic impairment.
• Glucocorticoids: intra-articular for mono/oligoarticular disease (favorite in hospitalized patients). Systemic steroids if needed (e.g., prednisone ~0.5 mg/kg/day with short taper) when NSAIDs/colchicine won’t fly.
• NSAIDs at anti-inflammatory doses only if no CKD/HF/ulcer/CV risk. In many inpatients, avoid.
• Combination (short course) if pain control lags and no contraindications (e.g., colchicine + steroid).
• Refractory/intolerant? Consider IL-1 blockade (anakinra off-label, canakinumab where available) after infection is excluded.

Hospital pitfalls you don’t want to meet: delayed treatment, stopping chronic urate-lowering therapy (ULT) on admission without cause, wrong colchicine dose, NSAIDs in CKD/HF, or forgetting drug–drug checks (macrolides, azoles, cyclosporine).

Treat-to-target that sticks (after the flare settles or continue if already on):
• Indications for ULT: recurrent flares, tophi, erosive disease (and often CKD).
• Allopurinol first-line: start low (≤100 mg/day; lower with CKD) and titrate q3–6 weeks to serum urate <6 mg/dL (≤5 mg/dL if heavy tophi). CKD is not a reason to cap the dose—titrate with labs.
• Prophylaxis during ULT changes: colchicine 0.5–0.6 mg daily (or low-dose NSAID/pred if colchicine isn’t an option) for 3–6 months, and at least 1 month after hitting target and flare-free.
• Febuxostat if allopurinol-intolerant—use caution in ASCVD. Uricosurics if good renal function; pegloticase for refractory tophaceous disease.
• Safety moves: consider HLA-B*58:01 testing in high-risk ancestries (e.g., many Asian and Black populations) or CKD to reduce AHS risk; do med rec for colchicine interactions.

Patient & system moves: teach that gout is chronic, crystal-driven, and fixable with urate lowering; lifestyle tweaks help a bit but medication is the engine. Use the admission to (1) confirm gout, (2) start/titrate ULT when appropriate, (3) prescribe prophylaxis, (4) schedule labs/follow-up, and (5) hand over a clear flare plan.

Fast, crystal-proven, and target-driven—aspirate when you can, tailor the anti-inflammatories, and lock in SU <6 mg/dL so flares fade and tophi melt.